PEDIATRIC HEMATOLOGY ONCOLOGY

SAUDI FELLOWSHIP PROGRAM

FELLOWSHIP FINAL CLINICAL EXAMINATION OF

PEDIATRIC HEMATOLOGY ONCOLOGY

(2018)

2

I Objectives

a. Determine the ability of the candidate to practice as a specialist and provide consultation in the general domain

of his/her specialty for other health care professionals or other bodies that may seek assistance and advice.

b. Ensure that the candidate has the necessary clinical competencies relevant to his/her specialty including but not

limited to history taking, physical examination, documentation, procedural skills, communication skills,

bioethics, diagnosis, management, investigation and data interpretation.

c. All competencies contained within the specialty core curriculum are subject to be included in the examination.

II Eli gibility

a. Passing Fellowship final written examination and fulfilling program requirements.

b. Candidate is allowed a maximum of four attempts to pass the final clinical/practical examination of

board certificate within a period of five years from successfully passing the final written examination

provided evidence of continuing clinical practice is presented and approved by the Scientific Council.

c. Upon the recommendation of the scientific specialty council, a candidate who failed to pass the

clinical/practical examination with the specifications mentioned above in item (2) has to pass final written

examination again, after which he/she is allowed to sit the final specialty clinical/practical examination

twice provided that evidence of continuing clinical practice is presented and approved by the scientific

specialty council.

d.

After exhausting above attempts candidate is not permitted to sit the Saudi Fellowship final specialty clinical

examination.

III General Rules

a. If the percentage of failure in the clinical examination are 50% or more the examination shall be repeated after

6 months.

b. Specialty clinical examinations shall be held on the same day and time in all centers, however if

multiple consecutive sessions are used, suitable quarantine arrangements must be in place.

c. If examination is conducted on different days, more than one exam version must be used.

IV Exam Format

a. The Pediatric Hematology Oncology final clinical examination shall consist of 10 graded stations each

with 10 minute encounters.

b. The 10 stations consist of 7 Objective Structured Clinical Exam (OSCE) stations with 1 examiner each and

3 Structured Oral Exam (SOE) stations with 2 examiners each.

c. All stations shall be designed to assess integrated clinical encounters.

d. SOE stations are designed with preset questions and ideal answers.

e. Each OSCE station is assessed with a predetermined performance checklist. A scoring rubric for post-

encounter questions is also set in advance.

3

V Final Clinical Exam Blueprint*

DIMENSIONS OF CARE

Health Promotion &

Illness Prevention

1±1 Station(s)

Acute

5±1

Station(s)

Chronic

3±1

Station(s)

Psychosocial

Aspects

1±1

Station(s)

# Stations

DO

MA

INS

FO

R I

NT

EG

RA

TE

D

CL

INIC

AL

EN

CO

UN

TE

R

Patient Care

7±1 Station(s) 1 4 2 7

Patient Safety &

Procedural Skills

1±1 Station(s)

1 1

Communication &

Interpersonal Skills

2±1 Station(s)

1 1 2

Professional Behaviors

0±1 Station(s) 0

Total Stations 1 5 3 1 10

*Main blueprint framework adapted from Medical Council of Canada Blueprint Project

4

VI Definitions

Dimensions of Care Focus of care for the patient, family, community, and/or population

Health Promotion &

Illness Prevention

The process of enabling people to increase control over their health & its determinants, & thereby improve

their health. Illness prevention covers measures not only to prevent the occurrence of illness such as risk factor

reduction but also arrest its progress & reduce its consequences once established. This includes but is not

limited to screening, periodic health exam, health maintenance, patient education & advocacy, & community &

population health.

Acute

Brief episode of illness, within the time span defined by initial presentation through to transition of care. This

dimension includes but is not limited to urgent, emergent, & life-threatening conditions, new conditions, &

exacerbation of underlying conditions.

Chronic Illness of long duration that includes but is not limited to illnesses with slow progression.

Psychosocial Aspects Presentations rooted in the social & psychological determinants of health that include but are not limited to life

challenges, income, culture, & the impact of the patient`s social & physical environment.

Domains Reflects the scope of practice & behaviors of a practicing clinician

Patient Care

Exploration of illness & disease through gathering, interpreting & synthesizing relevant

information that includes but is not limited to history taking, physical examination &

investigation. Management is a process that includes but is not limited to generating,

planning, organizing care in collaboration with patients, families, communities,

populations, & health care professionals (e.g. finding common ground, agreeing on

problems & goals of care, time & resource management, roles to arrive at mutual decisions

for treatment)

Patient Safety & Procedural Skills

Patient safety emphasizes the reporting, analysis, and prevention of medical error that

often leads to adverse healthcare events. Procedural skills encompass the areas of clinical

care that require physical and practical skills of the clinician integrated with other clinical

competencies in order to accomplish a specific and well characterized technical task or

procedure.

Communication & Interpersonal Skills

Interactions with patients, families, caregivers, other professionals, communities, &

populations. Elements include but are not limited to active listening, relationship

development, education, verbal, non-verbal & written communication (e.g. patient

centered interview, disclosure of error, informed consent).

Professional Behaviors

Attitudes, knowledge, and skills based on clinical &/or medical administrative

competence, ethics, societal, & legal duties resulting in the wise application of behaviors

that demonstrate a commitment to excellence, respect, integrity, accountability & altruism

(e.g. self-awareness, reflection, life-long learning, scholarly habits, & physician health for

sustainable practice).

5

VII Passing Score

a. The pass/fail cut off for each OSCE/SOE station is determined by the exam committee prior to conducting the

exam using a Minimum Performance Level (MPL) Scoring System.

b. Each station shall be assigned a MPL based on the expected performance of a minimally competent candidate.

The specialty exam committee shall approve station MPLs.

c. At least one examiner marks each OSCE station and two examiners independently mark each part of the SOE.

d. To pass the examination, a candidate must attain a score >/= MPL in at least 70% of the total stations .

VIII Score Report

a. All score reports shall go through a post-hoc item analysis before being issued and approved by the SCFHS Assistant Secretariat for Postgraduate Studies and SEC within two weeks of the examination.

IX Exemptions

a. SCFHS at present has no reciprocal arrangement with respect to this examination or qualification by any other

college or board, in any specialty.

6

X OSCE Station Sample**

Internal Medicine

Clinical Exam

Station 1

Instructions to Resident

Scene: Emergency Room

You are called to see the patient; Ali Saeed, a 35-year-old who

presents with shortness of breath and chest pain for 4 weeks.

YOU HAVE 10 MINUTES TO DO THE FOLLOWING:

1) OBTAIN BRIEF RELEVANT HISTORY.

2) PERFORM A FOCUSED PHYSICAL EXAMINATION.

a. think aloud during the physical examination.

b. before performing any maneuver or intervention, inform the

patient of your intentions.

3) DISCUSS THE MOST IMPORTANT INVESTIGATIONS.

4) DISCUSS THE MOST PROBABLE DIAGNOSIS BASED ON

FINDINGS PROVIDED.

5) EXPLAIN THE DIFFERENT OPTIONS FOR MANAGEMENT TO THE

PATIENT.

7

Performance Evaluation: Station 1

0 = not done, 1 = attempted but not done correctly/completely, & 2 = done correctly/completely

Patient Care/Assessment 0 1 2

1. Obtains a focused history: (if mentions 5 give full mark).

SOB (severity; NYHA class, orthopnea, PND)

Chest pain (Site, severity; CCC, character, radiation, aggravating and relieving factors)

Other cardiac symptoms (palpitations, intermittent claudication and syncope).

Fever (diurnal variation, severity, associated sweating).

Loss of appetite and weight

Past history of TB or TB contact, joint pain and skin rash.

Social history (Smoking, illegal sex)

2. Performs focused cardiovascular examination:

Requests vital signs and attempts to check for "pulsus paradoxus"

Examine JVP (position at 45O, proper position of the neck, uses light, confirms JVP).

Attempted to examine the precordium examination.

Attempted to examine for hepatomegaly, auscultation of the base of the lungs and for lower limbs edema).

3. Mentions the most probable diagnosis:

Cardiac tamponade

4. Mentions the most important immediate investigations:

CBC, ESR, Renal functions, ANA and RF.

ECG

CXR

Echocardiogram

5. Interpretation of ECG: electrical alternans

6. Interpretation of CXR: Flask like cardiomegaly and clear lung fields.

7. Mentions the common causes: (if mentions 4 give full mark)

Viral/ idiopathic

TB

Uremic/ dialysis associated pericarditis

Malignancy

Pericardial empyema

Post MI

Autoimmune

Others

Management

8. Discusses the immediate management:

IVF resuscitation

Diagnostic and therapeutic pericardiocentesis

9. Further management:

Depends on the cause: - NSAID ± colchicine ± steroids for idiopathic and autoimmune diseases - Antibiotics for empyema - Anti-TB for TB - Dialysis for uremic pericarditis - Radio/ chemotherapy for malignancy - Pericardial window for recurrent pericardial effusion

Total marks:

8

Questioning Skills (ONE choice only)

Awkward, exclusive

use of closed-ended

or leading questions

and jargon

Somewhat awkward;

inappropriate terms;

minimal use of

open-ended

questions

Borderline

unsatisfactory;

moderately at ease;

appropriate language;

uses different types

of questions

Borderline satisfactory;

moderately at ease;

appropriate language;

uses different types

of questions

At ease; clear

questions; appropriate

use of open and

closed-ended

questions

Confident;

skillful

questioning

Professional Behavior with Patient (ONE choice only)

Offensive

or aggressive;

frank exhibition of

unprofessional

conduct

Negative attitude

toward patient

Borderline

unsatisfactory;

does not truly instill

confidence

Borderline satisfactory;

manner inoffensive,

but does not

necessarily instill

confidence

Attempts

professional manner

with some success

Overall demeanor

of a professional; caring,

listens, communicates

effectively

Overall Organization of Patient Encounter (ONE choice only)

No logical flow;

scattered, inattentive

to patient's agenda

Counsels patient

before taking history

or doing physical

Minimal organization;

scattered approach

Appropriate

approach

to patient

Skillful approach

to patient

Skillful, professional

approach to patient

and effective use

of time

Facilitation of Informed Decision Making (ONE choice only)

No attempt or

inappropriate attempt

at information sharing

(e.g., deception,

slanting of facts,

incorrect information)

Incomplete and / or

biased information;

overuses jargon;

does not ensure

understanding of

issues

Attempts to share

information; omits

some critical facts;

uses some jargon;

attempts to ensure

understanding

Gives some

information on most

important facts;

may use jargon;

attempts to ensure

understanding

Gives clear information;

supports patient

decision making

(e.g., alternatives, risks

/ benefits); appropriate

language; ensures

understanding

Organized; optimizes

patient decision making;

significant effort to make

information relevant;

clear language;

attentive to patient

understanding

9

ABHA MEDICAL CENTER

Patient name: Ali Saeed

Age : 35 years

Test Results Normal values

Hb 105 123- 157g/L

WBC 6.5 4.0-10.5 X 109/L

MCV 82 80 – 96 fl

MCH 33 28-33 pg/cell

Platelet 280 150 – 400 X 109/L

ESR 70 3-15 mm/hr

****************************************************************

ABHA MEDICAL CENTER

Patient name: Ali Saeed

Age : 35 years

ECG

10

ABHA MEDICAL CENTER

Patient name: Ali Saeed

Age : 35 years

CXR

********************************************************************

ABHA MEDICAL CENTER

Patient name: Ali Saeed

Age : 35 years

Echo-Doppler Report:

- Massive pericardial effusion

- Right ventricular diastolic collapse

- Dilated uncompressable inferior venacava

- Normal left ventricular dimentions and functions

11

XI SOE Station Sample**

STATION 2

Instructions to candidate:

A 60 year old man is referred to the cardiology clinic for further evaluation of chronic shortness of breath.

The patient is under the gastroenterology follow up for ascites with high SAAG for which there is no clear cause.

Question/Ideal Answers Mark

How would you approach this patient?

Focused History:

Details of SOB (NYHA class, orthopnea, PND)

Other cardiovascular symptoms (chest pain, palpitations, syncope, lower limb swelling)

Past history of pericarditis, hemopericardium, TB, renal impairment and chest radiotherapy

/6

Relevant Physical Examination:

Blood pressure

JVP

Examine for Pericardial knock.

Examine abdomen for Pulsating hepatomegaly and ascites.

Examine Chest for pleural effusion

Examine for lower limbs edema

/12

The patient has progressive SOB NYHA class III with orthopnea and PND over a 6months period. His past history is significant for CABG 2 years ago

which was complicated by hemopericardium and received blood transfusion. He noticed progressive abdominal distention for 2 months. Lately he

developed lower limb swellings in both sides. Hepatitis screening, Bilharzia serology, s. ferritin and ANA are negative. U/S abdomen showed

hepatomegaly, dilated hepatic veins and IVC. No focal lesions.

Physical examination: Pulse is irregular, BP 90/60 mmHg, elevated JVP which increases during inspiration. There is a loud sound shortly after S2.

Abdominal examination showed pulsating hepatomegaly and positive shifting dullness. Chest examination: fine basal crepitations. Has bilateral lower limb

pitting edema.

What is the differential diagnosis in this case?

Constrictive pericarditis

Restrictive cardiomyopathy

Cardiac tamponade

Advanced dilated cardiomyopathy

/12

What investigations would you like to conduct?

Serum BNP level

ECG

CXR Echo-Doppler

Cardiac CT or MRI

Left and right heart catheterization

/6

What are the positive findings of the given investigations?

ECG: Show the ECG (Low voltage QRS complexes, atrial fibrillation)

CXR: Show the CXR (pericardial calcification)

Echo-Doppler: Biatrial dilatation, normal ventricular systolic function and diastolic dysfunction with restrictive physiology

/6

Serum BNP level: normal

Cardiac CT or MRI: Biatrial enlargement, thickened pericardium with/ without calcification.

Left and right heart catheterization: Show the pressure tracing (Elevated right atrial pressure with prominent X & Y descent, square root sign in LV and RV diastolic pressure tracing and equalization in LV and RV diastolic pressure. Mirror image discordance between the LV & RV peak systolic

pressures)

What is the most likely diagnosis?

Constrictive pericarditis /10

What pathophysiological abnormality is responsible for heart failure in constrictive pericarditis?

Diastolic dysfunction. /10

Mention 4 common causes of constrictive pericarditis?

Post viral pericarditis Post cardiac surgery

Post radiotherapy

Post infectious (TB, purulent) Connective tissue disorders

Miscellaneous causes (uremia, sarcoidosis, drug induced, asbestosis).

/8

What is the definitive treatment of constrictive pericarditis?

Pericardiectomy /10

Total /80

12

13

**Examples are shown to clarify station structure regardless of case details.